A nurse at a community health center is preparing a presentation on alcohol use disorder. Which of the following risk factors should the nurse include in the presentation?

Rationale for correct choice:

• Determine the client's level of anxiety to check for the risk of self-harm: Assessing the client’s anxiety is vital in identifying any risk of self-harm or suicidal thoughts, especially after trauma. This helps the nurse provide appropriate interventions to ensure the client's safety.

Rationale for incorrect choices:

• Tell the client their consent is not required prior to collecting potential physical evidence: The nurse must obtain the client’s consent before collecting any physical evidence. Consent is a legal and ethical requirement, especially in cases of sexual assault.
• Ask the client if they often walk alone when out in public places: This question may inadvertently lead to feelings of guilt or self-blame and is not an immediate priority. The focus should be on addressing the trauma and the client's current needs.
• Avoid asking the client open-ended questions during the interview: Open-ended questions allow the client to express their feelings and experiences, which is essential in trauma care. Avoiding them could hinder the client’s ability to share and may limit the nurse’s understanding of the situation.

Rationale:

• Heart rate: The client's heart rate has increased to 124 beats per minute, which is significantly higher than normal. This tachycardia could be a sign of neuroleptic malignant syndrome (NMS), a potentially life-threatening reaction to antipsychotic medications like haloperidol.
• Temperature: The client's elevated temperature of 39.5°C (103.1°F) is concerning and could be indicative of NMS, which often presents with hyperthermia as one of its hallmark symptoms. NMS is a medical emergency that requires immediate attention.

Rationale for incorrect choices:

• Vision report: The client's report of blurry vision may be a side effect of haloperidol, but it is not typically considered a life-threatening reaction. It should be monitored but does not indicate an immediate crisis.
• Blood pressure: While the blood pressure is slightly low, it is not as critical as the combination of elevated heart rate and temperature. The low blood pressure would require monitoring but is not immediately indicative of a life-threatening reaction.
• Mouth report: Dry mouth is a common side effect of many medications, including antipsychotics like haloperidol. While uncomfortable, it is not a life-threatening condition.
• Respiratory rate: The respiratory rate of 22/min is within normal limits and does not indicate any immediate concerns related to the medication. It should be monitored but does not raise a red flag for a life-threatening reaction.